SRG Research Assistantship Form

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SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM RESEARCH ASSISTANTSHIP FORM

This form must be submitted to the Clinical Research Centre, Level 4, Sultan Ahmad Shah Medical Centre @IIUM, Kuantan, Pahang

INSTRUCTION:

1. Please take note that the appointment of Research Assistant shall be made by Head of DEAR, upon recommendation from the Principal Investigator.

2. Research Assistantship Form shall only be fill up by the Principal Investigator (PI).

3. Please take note that the attendance of every research assistant’s which is approved by PI, is required prior to the release of payment.

4. Please ensure that the recommended Research Assistant fulfill the eligibility criteria as stated below.

3.1 Malaysian or non-Malaysian nationality.

3.2 If IIUM staff is planned to be appointed, please ensure that the research activity does not interfere with his/her actual work.

3.3 An immediate or extended family members of the researchers’ team are NOT eligible to apply

5. Please ensure all required supporting documents are attached with the completed form, as stated in the checklist below.

No Items - Please TICK (√) the applicable boxes. Checklist

1 Completed Form with signature

2

Supporting documents are attached with the completed form

 Copy of NRIC/ Passport

 Copy of Staff Card/ Matric Card (If applicable)

 Copy of bank account

 NDA between RA and SASMEC

FOR OFFICE USE

Document Complete / Incomplete

Date: ……….

Received by:

Name : ………..

Position: ………...…

Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur.

Tel: 09-591 2500

SASMEC-DEAR-CRC(SG)-F015 VER: 01 REV: 02 EFFECTIVE DATE: 03 OCTOBER 2022

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SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM RESEARCH ASSISTANTSHIP FORM

A. REQUESTOR INFORMATION Name of Requestor

NRIC / Passport No Staff No

Office No Mobile No

Email Address K/C/D/I/O Project ID Project Title

B. RESEARCH ASSISTANT INFORMATION Name of Research

Assistant

Nationality Malaysian

Non-Malaysian (Please state country of origin, if non-Malaysian)

Status IIUM Staff SASMEC Staff IIUM Student Non-IIUM Staff No/Matric No

(if applicable) NRIC / Passport No

Office No (if

applicable) Mobile No

Email Address K/C/D/I (if applicable) Mail Address

Bank Account No Amount (RM)

Start Date (Date of Employment)

End Date

C. DECLARATION BY APPLICANT

I, the requestor of the above, hereby declare that all the information given are TRUE and I have duly completed this form and attached all required supporting documents as in the checklist.

Signature and Stamp:

Date:

D. DEPARTMENT OF EDUCATION AND RESEARCH

Verified by: Approved by:

Tel: 09-591 2500

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SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM RESEARCH ASSISTANTSHIP FORM

Signature & Stamp:

Date:

Approved : Not Approved :

Remarks :

Signature: & Stamp:

Date:

Tel: 09-591 2500